Fern Plant

The PRECEDE-PROCEED Model
Origins and Evolution

Introduction 

 

The PRECEDE-PROCEED Model of health program planning, implementation and

evaluation has built on a thread of continuity in work by Dr. Lawrence W. Green and his

colleagues, students, postdoctoral fellows and collaborators over 50 years. 

 

Their sequential collaborations developed during his series of full-time and visiting, sabbatical

or short-term appointments at UC Berkeley, the Population Council - Bangladesh, Johns

Hopkins, the US Public Health Service Office of Health Information and Health Promotion,

Harvard, the University of Texas, Maastricht University in the Netherlands, Newcastle

University in Australia, the Kaiser Family Foundation, the University of British Columbia in

Canada, UNICEF in China, Health 2000, CDC, Emory University, University of Maryland,

and the University of California at San Francisco. This array of venues assured an assembly

of observations, consultations, experiments, and conclusions that had broad generalizability

and applicability.

 

It also builds on the consultations, co-authorships, published applications and feedback of

hundreds of practitioners and researchers who have used, tested, and advanced the model

through their published research, program planning, implementation, evaluation,

consultations, training on and reviews of or amendments and commentaries on the model.

Each of the universities and agencies mentioned above are owed a debt of gratitude for the

homes they provided at various stages of our careers and in the evolution of the model. 

Origins of PRECEDE-PROCEED 

 

PRECEDE refers by way of acronym to predisposing, reinforcing and enabling constructs in educational/economic diagnosis and evaluation. It refers more broadly to the “diagnostic” stages “preceding” and during planning. PROCEED refers to the policy, regulatory, and organizational constructs in educational and environmentaldevelopment. It refers to the stages of “proceeding” with implementation and evaluation after initial planning. It has evolved with our belief, among others, that “if we want more evidence-based practice, we need more practice-based evidence” (Green & Ottoson, 2004).  

 

PRECEDE-PROCEED is a framework intended to aid practitioners and researchers in supplementing their reviews of the scientific literature for evidence-based practices with ways to generate practice-based evidence. It follows the awareness of a perceived health problem, and documents it with community consultation, participatory research and review of literature. It then produces population- and practice-based evidence about the needs, fit, and execution of programs required for health development, promotion, or protection in the specific communities or settings where they would be applied. 

The model originated as a cost-benefit evaluation framework (Green, 1974) from converging streams of research and experience in public health (Rogers, 1960), medical care (Andersen, 1968), family planning (Green, 1970a), psychological and social factors in health behavior (Green, 1970b), diffusion and adoption theory (Green, 1970a, 1975), other models of change (Green, 1976), and the demands of that period on health programs to demonstrate their effectiveness through evaluation in cost-effectiveness and cost-benefit metrics. 

 

 

 

 

 

 

 

 

 

Selected Initial Influences on PRECEDE and on PROCEED At the outset, the PRECEDE portion of the model included key elements of:

  • Ronald Andersen’s Behavioral Model of Families’ Use of Health Services;

  • Albert Bandura’s Social Learning Theory;

  • Godfrey Hochbaum and Irwin Rosenstock’s Health Belief Model;

  • J. Mayone Stycos’s decision model on couples’ adoption of family planning methods;

  • Kurt Lewin’s force-field analysis; and

  • methods and strategies in community-based participatory research.

The PROCEED portion of the model was further influenced by key aspects of:

  • the Health Field Concept of Laframboise;

  • the Lalonde Report for Health Canada;

  • the Ottawa Charter of WHO; and

  • the collective experiences of our global colleagues.

 

Visit the PRECEDE-PROCEED Wikipedia page for a condensed version of the origins and evolution of the model through its fourth edition.

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The model was first applied systematically in a series of clinical and field trials that confirmed its utility and predictive validity as a planning tool as well as an organizing framework for the variety of social, behavioral, epidemiological, administrative, and policy  sciences bearing on the planning and evaluation of programs, especially within our early  Johns Hopkins experimental trials (e.g., Green, Levine & Deeds, 1975;  Levine et al, 1979; Morisky et al, 1980, 1981, 1982, 1983). 

Evolution of PRECEDE-PROCEED

The model has evolved over time, with accumulating experience and research on the model as it was trialed in varied settings, health or behavioral problems, and populations.  A summary of the evolution is found here, along with relevant reference. The further history of the model can be traced in the successive editions (Green, Kreuter, Deeds & Partridge, 1980 and Green & Kreuter 1992; 1999 a,b; 2004; and now 2022) and in the evolution of the PROCEED components of the model since the 1992 edition). 

 

The 1st edition of the full textbook representation of the model was in 1980 in the text Health Education Planning: A Diagnostic Approach with the coinage of the acronym, PRECEDE - Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (Green, Kreuter, Deeds, & Partridge, 1980). The context of the work in public health education during that era was heralded by the phrase from Congressional legislation calling upon policy makers and program planners to require and facilitate “maximum feasible participation” in the planning and execution of health programs.

 

Too many attempts at executing this requirement seemed to interpret the phrase as engaging the public in roles that substituted for paid employees in delivering programs, an interpretation that Daniel Patrick Moynihan called “maximum feasible misunderstanding.”  Hence, the effort in our first edition to build on genuine experience with lay community participants on planning committees in identifying their community health problems. 

 

The 2nd edition in collaboration with Marshall Kreuter (1991) of the textbook, Health Promotion Planning: An Educational and Environmental Approach, the original PRECEDE model was extended to encompass the wider environmental, policy and organizational factors that Green and Kreuter had found important in their respective roles in launching national and state programs of community health promotion from the Kaiser Family Foundation, the federal Office of Disease Prevention and Health Promotion, and the Centers for Disease Control and Prevention (as directors of their offices). Kreuter development with his CDC staff the Planned Approach to Community Health (PATCH) program of grants to states to help them mount community projects, many of which used, or developed parallel processes with those of the PRECEDE-PROCEED model. This was followed by Green’s development and direction at CDC of an Office of Science and Extramural Research that made grants to test the viability and effectiveness of participatory research methods in community organization for health.  

 

The acronym PROCEED - Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development - was coined to capture these broader perspectives and our consulting and training experience in Africa, India, Bangladesh, China and other countries and with USAID, WHO and UNICEF. It also reflected the experience found in an evaluation of the CDC-sponsored PATCH program directed by Marshall Kreuter where state health departments made grants to counties and other localities for the planned approach to community health. 

 

In the 3rd edition of Health Promotion Planning: An Educational and Ecological Approach, in 1999, Green and Kreuter added dimensions of health promotion planning from their international experience in Canada, Europe, China, Australia, Singapore, Japan, and Africa.  Translations of the 2nd edition into Chinese and Japanese, and condensed versions in French, Spanish, Dutch, various other European and Asian languages had reached wider audiences of practitioners, researchers and policy makers who produced a growing list of published applications and tests of the model.  

Computer application. They also collaborated with Robert Gold, and colleagues including  Maria Fernandez (co-author of a chapter in the 2022 edition) to produce the EMPOWER software, and to add a chapter on technology applications of the PRECEDE-PROCEED model to the book. The PRECEDE-PROCEED Model is the framework around which Green and Kreuter later teamed with Robert Gold, then Dean, now Professor Emeritus of the College of Health and Human Performance at the University of Maryland, to build EMPOWER (a CD-ROM software andmanual) to provide technical guidance and assistance to those involved in the complex process of planning and implementing community-level cancer prevention and control interventions. This computer system, EMPOWER (Enabling Methods of Planning and Organizing Within Everyone's Reach) was used in workshops on the PRECEDE-PROCEED model at the University of British Columbia, University of Montreal, Johns Hopkins, and other universities and health agency sponsors. 

 

Following the 3rd edition, Laura A. Linnan, and her colleagues at the University of North Carolina conducted in 2001 a survey of the 253 universities offering graduate or undergraduate degree specialization in health education or health promotion, determining that the Precede-Proceed Model was taught by 88% of respondents, used by 85.7% in teaching, and used by 74.6% in practice, the most among 10 planning models listed. The respondents also ranked PRECEDE-PROCEED highest among the 10 planning models on usefulness for research (86%), and usefulness for practice (90.8%). Linnan later provided consultation to Green & Kreuter in their preparation of the 4th edition. 

 

The 4th edition, Health Program Planning: An Educational and Ecological Approach (New York: McGraw-Hill, 2005) by Green & Kreuter, built heavily on their respective experiences in executive positions as Directors of major programs. Green was Acting Director of the CDC Office on Smoking and Health, then Director of the Office of Science & Extramural Research; Associate Director for Prevention Research and Academic Partnerships, Public Health Practice Program Office. Kreuter was the initial Director of the CDC office that funded Prevention Research Centers at Schools of Public Health across the US. 

Both Co-Editors had served in or directed such research centers on health promotion and prevention research at Johns Hopkins, Emory University, the University of Texas Health Science Center at Houston, and the University of British Columbia. Green had chaired national Research Council and Institute of Medicine Committees and co-edited their reports on Preventing Drug Abuse: What Do We Know? (Gerstein and Green, 1993); Linking Research and Public Health Practice: A Review of CDC’s Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention (Stoto, Green & Bailey, Eds, 1997); and An Integrated Framework for Assessing the Value of Community-Based Prevention (Institute of Medicine Committee on Valuing Community-Based, Non-Clinical Prevention and Public Health Practice, 2012). 

 

The 2022 edition. The 2022 publication by Johns Hopkins University Press of Health Program Planning, Implementation, and Evaluation: Creating Behavioral, Environmental and Policy Change, represents a 5th in the series of textbooks as PRECEDE-PROCEED. Click here for a more in-depth exploration of the 2022 edition. 

Back to PRECEDE-PROCEED Origins 

 

We return to the conclusion we reached years ago, as our experience and consultations led us to bring the planning and implementation efforts we conducted or observed full circle to the conclusions they collectively demonstrated in evaluations: “If we want more evidence-based practice, we need more practice-based evidence.”  Such evidence demands: 

 

  • the active engagement of the community to be served; 

  • the systematic collection and analysis of diagnostic data starting with ultimate values of their health-related quality of life and social conditions causing or resulting from their health condition;

  • continue working backwards in the causal chain of determinants of health to find the most important and changeable ones at each level of causation;

  • design interventions that would achieve the changes required at each level, setting quantitative objectives for the practice-based evidence to assure their achievement; 

  • evaluate the achievement of objectives.

References 

​Anderson, R. A Behavioral Model of Families Use of Health Services. Chicago: University of Chicago, Center for Health Administration Studies, Research Series No. 25, University of Chicago Press, 1985. 

 

Gerstein, D.R. & Green, L.W. Preventing Drug Abuse: What Do We Know? Committee on Drug Abuse Prevention Research, Commission on Behavioral and Social Sciences and Education, National Research Council, Washington, DC: National Academy Press, 1993. 

  

Gold, R.S., Green, L.W. & Kreuter, M.W. EMPOWER: Enabling Methods of Planning and Organizing Within Everyone's Reach.  Sudbury, MA: Jones & Bartlett Publishing, 1998 (software and manual, now out of print). 

 

Green, L.W. Toward cost benefit evaluations of health education: Some concepts, methods, and examples. Health Education Monographs 21(Suppl1)): 34-64, 1974. 

 

Green, L.W., Gielen, A.C., Ottoson, J.M., Peterson, D. V., & Kreuter, M. W., Health Program Planning, Implementation, and Evaluation: Creating Behavioral, Environmental and Policy Change. Baltimore: Johns Hopkins University Press, 2022.

 

Green, L.W. & Kreuter, M.W. Health Program Planning: An Educational and Ecological Approach. 4th edition. NY: McGraw-Hill Higher Education, 2005.   

 

Green, L.W. & Kreuter, M.W. Health Promotion Planning: An Educational and Ecological Approach, 3rd edition. NY: Mayfield Publishing was purchased by McGraw-Hill in 1999.

 

Green, L.W. & Kreuter, M.W. Health Promotion Planning: An Educational and Environmental Approach, 2nd edition. Palo Alto: Mayfield Publishing Co., 1991.

 

Green, LW, Kreuter, M.W., Deeds, S. & Partridge, K. Health Education Planning: A Diagnostic Approach. Palo Alto, CA:  Mayfield Publishing Co., 1980. [first edition]

 

Green, L.W. & Kreuter, M. W.  CDC's Planned Approach to Community Health as an application of PRECEDE and an inspiration for PROCEED. Journal of Health Education 23: 140-147, 1992. 

 

Green, L.W. & Ottoson, J.M. Community & Population Health, 8th edition. New York: WCB-McGraw-Hill, 1999.

 

Green, L.W. & Ottoson, J.M. From efficacy to effectiveness to community and back: Evidence-based practice vs practice-based evidence. In Green, L, Hiss, R., Glasgow R., et al. (Eds). From Clinical Trials to Community: The Science of Translating Diabetes and Obesity Research. Bethesda: National Institutes of Health, 2004, pp. 15-18. 

 

Kahan, S., Gielen, A.C., Fagan, P.J., & Green, L.W. Health Behavior Change in Populations. Baltimore: Johns Hopkins University Press, 2014. 

  

Kreuter, M.W., Lezin, N., Kreuter, M., & Green, L.W. Community Health Promotion Ideas That Work, 2nd edition. Boston, Toronto, London, Singapore: Jones & Bartlett Publishers, 2003. 

 

Linnan, L., Sterba, K.R., Lee, A.N., Bontempi, J.B., Yang, J., & Crump, C.  Planning and the professional preparation of health educators: Implications for teaching, research, and practice. Health Promotion Practice 6(3): 308-319, 2005. 

 

Morisky, D.E., Levine, D.M., Green, L.W., Russell, R.P., Smith, C.  The relative impact of health education for low- and high-risk patients with hypertension. Prev. Med. 9(4):550-558, 1980. [Abstract]

 

Morisky, D.E., Levine, D.M., Wood, J.C., Bone, L.R., Flagle, C., Green, L.W.  Systems approach for the planning, diagnosis, implementation and evaluation of community health education approaches in the control of high blood pressure. J. Operations Res. 50:625-34, 1981. 

 

Ottoson, J. M., & Green, L. W. Public health education and health promotion. In L. F. Novick, & G. P. Mays (Eds.). Public health administration: Principles for population-based management. (Pp. 300-323). Gaithersburg, MD: Aspen Publishers, Inc. 2nd edition, 2006.

Porter, C.M. Revisiting Precede–Proceed: A leading model for ecological and ethical health promotion. (2015-2016). Health Education Journal, 75 (6). https://doi.org/10.1177/0017896915619645

 

Rogers, E.S. Human Ecology and Health: An Introduction for Administrators. New York: Macmillan & Co., 1960

 

Stoto, M.A., Green, L.W., & Bailey, L.A. Linking Research and Public Health Practice: A Review of CDC’s Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention. Washington, DC: National Academy of Science, Institute of Medicine, 1997.